Lumbar Compression Fractures

A Patient's Guide to Compression Fracture

Introduction

The bones, or vertebrae, that make up your spine are very strong, but sometimes
a vertebra can fracture just like any other bone in your body. Vertebra fractures
are usually due to conditions such as: osteoporosis (a condition which weakens
the bones), a very hard fall, excessive pressure, or some kind of physical injury.

When a bone in the spine collapses, it is called a vertebral compression fracture.
These fractures happen most commonly in the thoracic spine (the middle portion
of the spine), particularly in the lower vertebrae of the thoracic spine.

The purpose of this document is to help you understand:

The anatomy of the spine relating to compression fractures

The causes and symptoms of compression fractures

How the condition is diagnosed

The treatments available for the condition

Some complications associated with compression fractures

Anatomy

To best understand lumbar spine injuries, it helps to know some anatomy of
the overall spine.

Compression fractures of the spine usually occur at the bottom part of the
thoracic spine (T11 and T12) and the first vertebra of the lumbar spine (L1).

Compression fractures of the spine generally occur from too much pressure on
the vertebral body. This usually results from a combination
of bending forward and downward pressure on the spine. For example, falling
from a chair in a sitting position on the floor usually causes your head to
go forward at the same time your buttocks hit the floor. This causes the spine
to bend forward concentrating the pressure on the front part of the spine -
the vertebral bodies. The fracture occurs when the bone actually collapses and
the front (anterior) part of the vertebral body forms a wedge shape. The cancellous
bone on the inside of the vertebral body is crushed, or compressed. In very
severe compression fractures, the back of the vertebral body may actually protrude
into the spinal canal and put pressure on the spinal cord. Fortunately, this
is not a common occurrence.

Causes

There is not one single cause of compression fractures, though the word compression
would indicate that the fracture occurs because of too much pressure being placed
on the bone. If the bone is too weak to hold normal pressure, it may not take
much pressure to cause the vertebral body to collapse. Most healthy bones can
withstand a lot of pressure and the spine will bend to absorb the shock. However,
if the force is too great for the vertebrae to sustain, one or more of them
can fracture. To understand a fracture, think about bending a pencil. If you
place pressure on the pencil, it will bend a little then go back into place
when the pressure is gone. However, if you bend the pencil too far - past its
breaking point, it will crack or break apart. Similarly, the amount a vertebra
collapses/fractures depends upon the amount of pressure it has to withstand.

A common cause of compression fractures is the disease osteoporosis. This disease
thins the bones, often to the point that they are too weak to bear normal pressure.
The thinning bones can collapse during normal activity, leading to a spinal
compression fracture. In fact, spinal compression fractures are the most common
type of osteoporotic fractures. Forty percent of all women will have at least
one by the time they are 80 years old. These vertebral fractures can permanently
alter the shape and strength of the spine. The fractures usually heal on their
own and the pain goes away. However, sometimes the pain can persist if the crushed
bone fails to heal adequately.

In severe cases of osteoporosis, actions as simple as bending forward can be
enough to cause a "crush fracture", or spinal compression fracture. This type
of vertebral fracture causes loss of height and a humped back, especially in
elderly women. This disorder (called kyphosis or a "dowager's hump") is an exaggeration
of your spine that causes the shoulders to slump forward and the top of your
back to look enlarged and humped.

Trauma to the spinal vertebrae can also lead to minor or severe fractures.
Such trauma could come from a fall, a forceful jump, a car accident, or any
event that stresses the spine past its breaking point.

Another cause of vertebral fractures is a metastatic disease. Metastasis is
a term that refers to the spread of cancer cells into other areas of the body.
The bones of the spine are a common place for many types of cancers to spread.
A compression fracture of the spine that appears for little or no reason may
be the first indication that an unrecognized cancer has spread to the spine.
The cancer causes destruction of part of the vertebra, weakening the bone until
it collapses. This is a sign that something going on internally is harming the
bones.

Symptoms

If the fracture is caused by a sudden, forceful injury, you will probably feel
severe pain in your back, legs, and arms. You might also feel weakness or numbness
in these areas if the fracture injures the nerves of the spine. If the bone
collapse is gradual - such as a fracture from bone thinning, the pain will usually
be milder. There might not be any pain at all until the bone actually breaks.

Diagnosis

In order for a fracture to be diagnosed, you will need to visit a health care
provider. Before your doctor can diagnose your condition and design a treatment
plan, a complete history and physical examination are necessary. There are many
possible internal causes of pain. It is important to determine what is and is
not the root of the problem. After the physician has a better idea of what is
causing your discomfort, diagnostic tests of some sort may be recommended.

History

First, you will be asked for a complete history of your condition. This may
begin by filling out a written form that asks you a number of questions relating
to your pain. The more information you share with your provider, the easier
your problem will be to diagnose. Your history is important because it helps
your doctor understand: when the pain began, anything that could have caused
an injury, physical factors that might be causing the pain, and any family history
of similar problems. After reading through your written history, your physician
will ask more questions that relate to the information you have given.

Some typical questions include:

Where do you feel the pain? What is the intensity?

Does the pain radiate to other parts of the body?

What factors make the pain feel better or worse?

Have you had problems with your bladder or bowels?

Physical Examination

After taking your history, the physician will give you a physical examination.
This allows the doctor to rule out possible causes of pain and to try to determine
what is causing your problem. The areas of your body that will be examined depend
upon where you are experiencing pain - neck, lower back, arms, legs, etc. Neurological
problems are rare except in younger patients who have experienced a violent
injury, such as a car crash.

If a compression fracture is suspected, the doctor will also test for point
tenderness near specific vertebrae. Testing specific areas for unusual tenderness
allows the doctor to narrow down the cause of your pain.

If a fracture is thought to exist, an X-ray of the spine will generally confirm
its presence. An X-ray is a painless process that uses radioactive materials
to take pictures of bone. X-rays show bones, but not much soft tissue, so X-rays
will definitely be used if fractures are suspected.

If there is a fracture, your doctor may also suggest a CAT scan to make sure
that the fracture is stable. The CAT scan is an X-ray test similar to both the
MRI and a regular X-ray, because it can show both bones and soft tissues. CAT
scans are also able to produce X-ray "slices" taken of the spine, so each section
can be examined separately. The scan forms a set of cross-sectional images.
With a compression fracture, an up and down perspective of the spine will be
pieced together for examination of stability. The CAT scan is usually done to
see if the nerves are in danger from the fracture.

A neurological exam will also be given. This allows the doctor to test your
neurological responses, such as your reflexes, muscles, and sensory perception.
Abnormalities on the neurological examination can point to nerve damage. The
nerves of the spinal cord carry messages from the brain to the rest of the body.
If there is damage to the spinal nerves, your body movement and neurological
responses will be affected.

If there is a chance that nerves are involved in the fracture, or if there
is some question about what is causing the pain, an MRI might be recommended.
The MRI scan is a fairly new test that does not use radiation. By using magnetic
and radio waves, the MRI creates computer-generated images. The MRI is able
to cut through multiple layers of the spine and show any abnormality of soft
tissues, such as nerves and ligaments.

A nuclear bone scan is another diagnostic test that might be ordered. This
test helps determine the age of a fracture. If the fracture is old and there
appear to be other fractures that have healed, this may indicate osteoporosis
(bone-thinning disease) is causing the fractures. This is important in older
patients, particularly women. In this case, treatment of the fracture will include
preventive measures to try to stop other vertebral fractures from occurring.
Such treatment could include: calcium supplements, increased vitamin D, weight-bearing
exercises, and hormone replacement therapy for women.

For more information on all these tests, you may wish to review the document,
entitled:

You will most likely have to limit your normal activities. You should avoid
any strenuous activity or exercise. You will definitely need to avoid heavy
lifting and anything else that might place too much strain on your fractured
vertebra. If you are elderly, your doctor might also put you on bed rest. Older
bones take longer to heal and are typically thinner and weaker than younger
bones. Treat this fracture as you would any other broken bone, carefully and
seriously.

Bracing

Another common form of treatment for some types of vertebral compression fractures
is bracing. Your doctor may prescribe a back support (often officially called
an orthosis). The brace supports the back and restricts movement; just as an
arm brace would support a fracture of the arm. The brace is well molded to conform
tightly to your body, like a cast for any other fracture. The brace used to
treat a compression fracture of the spine is designed to keep you from bending
forward. It holds the spine in hyperextension (meaning more extension, or straightening,
than normal). This takes most of the pressure off the fractured vertebral body,
and allows the vertebrae to heal. It also protects the vertebra and stops further
collapse of the bone.

Vertebral fractures usually take about three months to fully heal. X-rays will
probably be taken monthly to check on the healing progress.

To learn more about the different types of braces available to treat compression
fractures, you may wish to review the document, entitled:

Surgery to fix most spinal compression is rarely needed. With vertebral fractures,
surgery, or internal fixation, is only considered if there is evidence of sudden
and serious instability of the spine. For instance, if the fracture leads to
a loss of 50% of the vertebral body's height, surgery might be necessary to
prevent damage that is more serious to the spinal nerves.

If your doctor feels that surgery is necessary to treat your fracture, he or
she will probably suggest using some type of internal fixation to hold the vertebrae
in the proper position while the bone heals. If there are signs that there is
too much pressure on the spinal cord, the bone fragments pushing into the spinal
cord may also need to be removed.

Anterior Approach

When surgery is necessary to remove pressure from the spinal cord, your surgeon
may suggest an operation from the front of the spine. During an anterior approach
an incision is made in the chest to allow the surgeon to see the front of the
spine and locate the vertebra that has been crushed. Once the vertebra has been
located, the bone fragments may be removed to remove the pressure from the spinal
cord. Once this has been accomplished, a spine fusion is usually performed.

The anterior spine fusion is performed by replacing the crushed vertebra with
bone graft to hold the vertebra above and below the fractured vertebra apart.
The bone graft eventually grows together with the vertebra above and below,
and fuses the vertebrae together into one bone. During the operation a combination
of metal screws, metal plates and metal rods are used to hold the spine in the
correct position to allow the fusion to occur over the next several months.
These metal implants will remain in the body and will not be removed unless
they contribute to the patients problems.

Posterior Approach

In some cases, an operation to stabilize the fractured vertebra can be performed
through an incision in the back. This type of procedure can allow the surgeon
to use metal screws and metal rods to hold the vertebrae in the correct alignment
while the fractured vertebrae heals. The posterior approach is more useful when
there is not a great deal of pressure on the spinal cord and the surgeon is
trying to prevent the fractured vertebra from collapsing more.

For more information on this type of surgery, you may wish to review the document,
entitled:

Spinal surgery is obviously a serious undertaking. Because of the risks and
complications associated with spinal surgery, internal fixation is only done
in serious cases.

Complications

With any surgery, there is a risk of complications. When surgery is done near
the spine and spinal cord these complications (if they occur) can be very serious.
Complications could involve subsequent pain and impairment and the need for
additional surgery. You should discuss the complications associated with surgery
with your doctor before surgery. The list of complications provided here is
not intended to be a complete list of complications and is not a substitute
for discussing the risks of surgery with your doctor. Only your doctor can evaluate
your condition and inform you of the risks of any medical treatment he or she
may recommend.

Several specific complications can occur with a vertebral compression fracture.
If you notice or suspect a complication, please contact your doctor immediately.

Segmental Instability

If a fracture leads to a vertebral body collapse of more than 50 percent, there
is a risk of segmental instability. Each spinal segment is like a well-tuned
part of a machine. All of the parts should work together to allow weight-bearing,
movement, and support. A spinal segment is composed of two vertebrae attached
together by ligaments, with a soft disc separating them. The facet joints fit
between the two vertebrae, allowing for movement, and the foramen between the
vertebrae allow space for the nerve roots to travel freely from the spinal cord
to the body. When all the parts are functioning properly, all spinal segments
join to make up a remarkably strong structure called the spine. When one segment
deteriorates, or collapses, to the point of instability, it can lead to localized
pain and difficulties. The instability eventually results in faster degeneration
of the spine in this area.

Kyphotic Deformity

Though the thoracic spine is supposed to be curved (or kyphotic), if the curve
in a person's thoracic spine is more than 40 to 45 degrees, it is considered
abnormal. Sometimes this deformity is described as "round back posture" or "hunchback".
It is a common disorder in elderly women who have osteoporosis and frequent
fractures. The front of the vertebrae will collapse and wedge due to the lack
of normal vertebral space. This condition leads to a more rounded thoracic spine.

Neurologic Complications

If the fracture causes part of the vertebral body to place pressure on the
spinal cord, the nerves can be affected. There is some space between the spinal
cord and the edges of the spinal canal. However, this space can be reduced if
the pieces of the broken vertebral body push into the spinal canal. The bony
tube of the spinal canal cannot expand if the spinal cord or nerves require
more space. If anything begins to narrow the spinal canal - such as if the vertebrae
protrude into its space, the risk of irritation and serious injury of the spinal
cord or nerves increases.

The narrowing of the spinal canal due to a compression fracture can either
lead to immediate injury to the nerves of the spine, or irritation of the nerves
later. If the irritation on the spinal nerves comes later (even after the fracture
has healed), it can cause pain and problems with the nerves not working right.
The lack of space can also cause the supply of blood and oxygen to the spinal
cord to be reduced. When the spine needs more blood flow during increased activity,
the blood vessels may not be able to swell to get more blood to the spine. This
can lead to numbness and pain in the nerves that are affected. The nerves also
lose some of their mobility when the space available to them is reduced. This
leads to irritation and inflammation of the nerves. This condition is called
spinal stenosis. For more information on spinal stenosis, you may wish to review
the document, entitled:

All of these conditions may lead to the need for surgery in order to reduce
pressure on the spinal cord, or to stabilize the spine. Surgery might also be
necessary to reduce pain and/or the danger of neurological problems.